Recommendations against breastfeeding require consultation with women for effective implementation
Authors: Jane Fisher
Journal: The Lancet Global Health (2023)

Infection with human T-cell lymphotropic virus type 1 (HTLV-1) can be asymptomatic, but the virus can cause severe illnesses, including adult T-cell leukaemia–lymphoma or progressive neurological disease in adults. HTLV-1 can be contracted through blood transfusion, organ transplantation, needle sharing, or sexual contact; it can also be transmitted from mother to child through breastfeeding. Avoidance of breastfeeding can be recommended to minimise the risk of an infant becoming infected. In The Lancet Global Health, Carolina Rosadas and colleagues1Rosadas C Senna K da Costa M et al.Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility model.Lancet Glob Health. 2023; 11: e781-e790Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar assess the cost-effectiveness in Brazil of screening pregnant women for HTLV-1, and proscribing breastfeeding among those who are infected, to prevent mother-to-child transmission. The model was constructed from the perspective of the Brazilian unified public health system and it included costs of antenatal testing, prescription of cabergoline to inhibit lactation, and 6 months' supply of infant formula. The authors found that the intervention is cost-effective and it would have the potential to prevent HTLV-1 infection in more than 1000 babies every year in Brazil. This technically proficient analysis makes an important contribution to the understanding of HTLV-1 antenatal screening and postnatal interventions, with clear implications for health policy and practice. Nevertheless, several gaps remain. One of these gaps is the absence of explicitly elicited consumers' perspectives on the recommendations against breastfeeding, which is a crucial aspect that influences the uptake of these recommendations,2Brown A What do women lose if they are prevented from meeting their breastfeeding goals?.Clin Lactation. 2018; 9: 200-207Crossref Scopus (29) Google Scholar as acknowledged briefly by Rosadas and colleagues as part of the study limitations.1Rosadas C Senna K da Costa M et al.Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility model.Lancet Glob Health. 2023; 11: e781-e790Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar WHO recommends breastmilk as "the ideal food for infants",3WHOBreastfeeding.https://www.who.int/health-topics/breastfeeding#tab=tab_1Date accessed: February 28, 2023Google Scholar with benefits to health, growth, and immune function. Evidence suggests that, when other factors are controlled, infants who are breastfed have better cognitive development, higher intelligence quotients, and a larger brain volume than infants who are not breastfed.4Luby JL Belden AC Whalen D Harms MP Barch DM Breastfeeding and childhood IQ: the mediating role of gray matter volume.J Am Acad Child Adolesc Psychiatry. 2016; 55: 367-375Summary Full Text Full Text PDF PubMed Scopus (42) Google Scholar Breastfeeding promotes protective emotional attachment between mothers and their infants. Women who are pregnant experience pervasive advocacy for breastfeeding: information promoting breastfeeding is given to women in maternity services, is displayed on noticeboards, and is discussed in antenatal clinical consultations and education and in postpartum care. The Baby-Friendly Health Initiative is a project launched by WHO and UNICEF in 1991, which aims to promote and support breastfeeding through a 10-step plan for maternity services. The plan provides several recommendations; for example, all infants should be put to the breast within 1 h of birth, and they should be fed only breastmilk for the first 6 months of life, followed by breastmilk with supplementary foods up to age 2 years.5WHOCompetency verification toolkit: ensuring competency of direct care providers to implement the baby-friendly hospital initiative. World Health Organization, Geneva2020Google Scholar Maternity hospitals that are accredited by the Baby-Friendly Health Initiative do not provide infant formula. Contemplation of breastfeeding often begins early in life, with young children mimicking breastfeeding with dolls and adolescent girls forming an intention to breastfeed.6Swanson V Power K Kaur B Carter H Shepherd K The impact of knowledge and social influences on adolescents' breast-feeding beliefs and intentions.Public Health Nutr. 2006; 9: 297-305Crossref PubMed Scopus (67) Google Scholar Most women who are pregnant intend to breastfeed.7Cordero L Oza-Frank R Moore-Clingenpeel M Landon MB Nankervis CA Failure to initiate breastfeeding among high risk obstetrical patients who intended to breastfeed.J Neonatal Perinatal Med. 2016; 9: 401-409Crossref PubMed Scopus (13) Google Scholar Prohibition of breastfeeding is not psychologically benign. Women who want to breastfeed but are told they cannot have to manage complex competing psychological processes. The decision to prevent HTLV-1 mother-to-child transmission, with the possibility that women might not know they are carrying this potentially harmful virus, has to be positioned against a woman's sense of loss and grief at being unable to experience a valued life goal. Such a decision also puts mothers in the difficult situation of not being able to give their baby a planned optimal start in life. In contexts where most women breastfeed, not breastfeeding is a public marker of a private situation. Among women living with HIV, not breastfeeding is a stigmatising indicator of their own health,8Greene S Ion A Elston D et al."Why aren't you breastfeeding?": how mothers living with HIV talk about infant feeding in a "breast is best" world.Health Care Women Int. 2015; 36: 883-901Crossref PubMed Scopus (35) Google Scholar and it is associated with shame, self-blame, and lower social participation.9Suwankhong D Liamputtong P 'I was told not to do it but…': infant feeding practices amongst HIV-positive women in southern Thailand.Midwifery. 2017; 48: 69-74Crossref PubMed Scopus (4) Google Scholar Not breastfeeding might influence the relationship between a mother and her child in the long term and become a lasting source of regret. Therefore, it is also possible that guidance on the avoidance of breastfeeding will be resisted. Readers are not told whether avoidance of breastfeeding requires policing to ensure adherence.10Hvatum I Glavin K Mothers' experience of not breastfeeding in a breastfeeding culture.J Clin Nurs. 2017; 26: 3144-3155Crossref PubMed Scopus (23) Google Scholar HTLV-1 is most prevalent in resource-constrained settings. The costs to the health system are included in the model provided by Rosadas and colleagues,1Rosadas C Senna K da Costa M et al.Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility model.Lancet Glob Health. 2023; 11: e781-e790Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar but the economic costs to parents (possibly in low socioeconomic positions) of feeding with infant formula are only considered partially. The proposed intervention1Rosadas C Senna K da Costa M et al.Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility model.Lancet Glob Health. 2023; 11: e781-e790Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar involves provision of infant formula at no cost to parents for 6 months. However, babies and toddlers need milk feeds for much longer than 6 months and the explanation of the model does not elaborate on how this sustained need will be met. Formula requires safe preparation: a clean water supply, the purchase of and a means to sterilise bottles, sufficient literacy to read and follow instructions about appropriate concentration of formula powder, and access to refrigeration. Last, the authors did not consider the potential emotional costs of mother–child attachment when breastfeeding is avoided. Transmission of HTLV-1—a virus with potentially profound consequences for health and quality of life—is a substantial public health concern in countries where HTLV-1 infection is prevalent. Notwithstanding the importance of economic costs, effective uptake of antenatal screening and prohibition of breastfeeding requires sensitive ascertainment and comprehensive understanding of the human costs and consequences. As an essential component of effective implementation, researchers, policy makers, and health professionals should investigate and consult with women who are pregnant or have recently given birth about the decisions they might make in this situation and the factors they consider to be relevant to their decisions. I hold the Finkel Professorial Fellowship in Global Health, which is supported by the Finkel Family Foundation. Economic analysis of antenatal screening for human T-cell lymphotropic virus type 1 in Brazil: an open access cost-utility modelHTLV-1 antenatal screening is cost-effective in Brazil. An open-access model was developed, and this tool could be used to assess the cost-effectiveness of such policy globally, favouring the implementation of interventions to prevent HTLV-1 mother-to-child transmission worldwide. Full-Text PDF Open AccessWomen living with HTLV-1 should have the opportunity to make informed decisions on prevention of mother-to-child transmissionNo one could disagree with the title of the Comment by Jane Fisher1 in response to our health economic research2—ie, "Recommendations against breastfeeding require consultation with women for effective implementation". Such consultations with women living with human T-cell lymphotropic virus type 1 (HTLV-1) shaped our research,2 while the absence of antenatal screening excludes women from any shared decision making. We endorse the need for antenatal screening but ensuring optimal resource allocation is key and drove our economic analysis of HTLV-1 antenatal screening. Full-Text PDF Open AccessWomen living with HTLV-1 should have the opportunity to make informed decisions on prevention of mother-to-child transmissionWe (the authors and 70 Brazilians living with human T-cell lymphotropic virus type 1 [HTLV-1]; appendix p 1) read the Comment (May, 2023)1 by Jane Fisher with interest, and we would like to add our lived experience. Fisher's piece raises some emotive issues associated with not breastfeeding. However, we were concerned with the statement that "not breastfeeding might influence the relationship between a mother and her child in the long term".1,2 Full-Text PDF Open Access